A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
The Clinical Documentation Integrity (CDI) Specialist/Consultant serves as a trusted advisor to client organizations, providing expert guidance in clinical documentation practices that improve quality, accuracy, and compliance. This role combines clinical expertise, coding knowledge, and consultative skill to assess, educate, and support client CDI programs across diverse healthcare settings. The incumbent will partner with physicians, coding teams, and health information professionals to ensure documentation accurately represents the patient's severity of illness, risk of mortality, and care delivered-driving appropriate reimbursement and coding integrity.
Key Responsibilities:
Conduct detailed concurrent and retrospective clinical documentation reviews across client sites to identify documentation improvement opportunities. Collaborate with client physicians and leadership to clarify documentation and ensure accurate reflection of patient acuity and resource utilization. Develop and issue compliant physician queries, adhering to AHIMA and ACDIS standards. Educate and mentor client staff and providers on CDI best practices, coding principles, and documentation requirements. Analyze and report CDI findings and trends, offering actionable insights and recommendations for process improvement. Support client CDI program development and optimization, including workflow design, policy alignment, and performance metric tracking. Participate in implementation projects for CDI software tools and workflow redesign initiatives. Contribute to internal consulting knowledge base by sharing clinical, coding, and operational insights with peers and leadership. Represent the firm professionally with clients, maintaining confidentiality, accuracy, and high standards of consulting integrity. Travel up to 10% (as needed) for onsite assessments, education sessions, and client engagement activities.
Requirements:
Required Qualifications:
Active Registered Nurse (RN) License required. CCDS or CDIP required Must maintain current and active status for all professional licenses and certifications.
Note:
This specific role requires a clinical nursing background; Foreign Medical Graduates (FMGs) will not be considered.
Experience:
3-5 years of progressive CDI experience in acute care or consulting environments. Strong knowledge of ICD-10-CM/PCS, MS-DRG, APR-DRG, risk adjustment and clinical coding guidelines. Proven success in provider engagement and interdisciplinary collaboration. Experience supporting CDI or coding improvement initiatives in multiple facility or health system settings preferred.
Skills & Competencies:
Excellent written and verbal communication with a consultative and professional demeanor. Strong analytical and problem-solving abilities.? High proficiency in EHR and CDI technology (Epic, Cerner, Iodine, 3M, Nuance, or equivalent). Ability to balance multiple client projects with attention to detail and timelines. Independent, adaptable, and collaborative work style suited for a dynamic consulting environment.
Preferred:
Prior consulting firm experience or multi-client CDI support background. Exposure to outpatient CDI and risk-adjusted quality measures (e.g., HCCs, MIPS). Advanced education or training in clinical data analytics or quality improvement.
